As I put the finishing touches on this editorial the morning after the momentous midterm elections, one thing seemed clear: for the first time in American history, health care was one of the top issues that motivated voters. According to virtually every poll, it was the leading issue in many contests for the House of Representatives, and in some Senate and gubernatorial races.

But even putting aside this election’s outcome, it’s already apparent that health care policy will have a huge impact on future elections. Since health care is the central focus of this journal and its readers, and will remain at the forefront of public debate, I thought it might be useful to review some health care facts and trends, and clarify some terms that are often misunderstood, or even intentionally misinterpreted.

Though it would be hard to prove Woody Allen’s statement that “80% of success is just showing up,” it is more obviously true that 90% of your life is determined by your attitude toward what’s happening to you. That’s why it’s crucial to understand how the public’s attitude toward government involvement in health care has changed. For much of the 20th century it evolved at such a glacial pace that it would have been easy to miss the recent quicksteps that made it flip.

There were four major steps in this “sudden” transition:

The first was the inauguration of Medicare in 1962. As I noted in my column a year ago,1 government intrusion was, until then, anathema to medical professionals in general, and to the AMA in particular. But AMA membership has declined precipitously – only 15% of American physicians are now dues-paying members. About half of all physicians are employed, i.e. they are no longer directly concerned with billing and collecting fees. Without the constant drumbeat of opposition to government involvement in health care previously provided by the AMA and the medical profession, public opinion was bound to shift. Medicare is now widely viewed by doctors and their patients as indispensable, and Medicaid provides the major source of coverage for the poor, so the public no longer fears that further government involvement will bring an apocalypse.

A recent op-ed piece in Lancaster’s newspaper, the LNP, signed by Dr. Dwight Eichelberger and a group of 13 other local physicians, demonstrated the increasingly popular view among doctors that everyone is entitled to good health care, and society has a moral obligation to provide it.2 I’m certain many other physicians would have signed the piece if they’d had the opportunity to do so.

Second, passage of the Affordable Care Act in 2010, with its mandate to cover “pre-existing” conditions, accelerated acceptance of a government role in health care. By making coverage available for millions of the previously uninsured, the ACA showed – after some initial struggles – that government involvement could be beneficial. (If the original “government option” for those who couldn’t find coverage at a reasonable cost, had not been removed from the ACA to facilitate its passage, the government would have had an even bigger and more beneficial role.)

The third step was the proposal of “Medicare for all” by Sen. Bernie Sanders, in his 2016 campaign for the presidency. At the time it was widely viewed, particularly on the right, as a socialist fantasy and little more than a campaign slogan. No longer.

The fourth step that sealed the deal on the public’s acceptance of more government involvement in health care, was – paradoxically – the Republican Congress’s attempt to dismantle the ACA. First they eliminated the individual mandate, which required everyone to have insurance or pay a penalty, and would have spread the cost of care by enrolling the healthy; then they permitted stripped down policies; and finally, they blocked federal subsidies for insurance companies that offered lower premiums to those with lower incomes.

The reversal of public attitudes was completed when it became clear that if Congress chipped away at the ACA any further, many of the newly insured under the ACA would lose their coverage because of pre-existing conditions. It became necessary for members of Congress from both parties to pledge that “pre-existing conditions” wouldn’t bar anyone from obtaining health insurance.

Of course, the two political parties mean different things when they make this obligatory promise. It matters greatly whether the cost of coverage for pre-existing conditions is uncontrolled and therefore is unaffordable even if it is technically “available,” or whether premiums are capped, with the government providing coverage when the private market will not. The latter is, after all, just what the original ACA proposed.

Regardless, we have reached a point where the public is demanding more comprehensive coverage. In a Washington Post-Kaiser Family Foundation poll this year, 51 percent of Americans and 74 percent of Democrats said they support a single-payer plan.3,4 More than 120 members of Congress have signed on as co-sponsors of a bill called the “Expanded and Improved Medicare for All Act,” up from 62 in 2016. And at least 70 have joined Capitol Hill’s new Medicare for All Caucus.3

Medicare for All is not just a campaign slogan anymore, but it means so many different things to so many people that it could become a relatively meaningless one again. It has been estimated to cost huge sums, or to save huge sums, depending on how it is implemented, but the truth will obviously be somewhere between. When we look to other Western countries with government-controlled systems, all of which have better health outcomes at lower cost, there are many different models.

Canada’s is the most familiar system of single-payer. The government strictly controls prices and provides health insurance for most medical needs, with no out-of-pocket costs. Many people buy a supplemental private plan for faster service or freer access to testing, as well as coverage for prescription drugs. Critics contend this leads to a two-tier system.

The British system is more extreme, with the government owning hospitals and employing many specialists in the National Health Service. Those who can afford it, buy insurance for the small private system that provides faster service. France and Germany have preserved a system of private insurance, but it is highly regulated and – notably – everyone must participate. Other successful examples abound, particularly those in Scandinavia, the Netherlands, Australia, and New Zealand, but space doesn’t permit such an extended discussion of alternatives.

Lastly, though conservatives reject Medicare for All and insist that competition is good because it lowers prices, experience proves the opposite for health care. Competition between health systems leads to duplication of both services and expensive equipment, to massive spending on marketing, and even to the promotion of non-essential services. Health care doesn’t follow the ordinary laws of free markets because efficient markets require all parties to have relatively equivalent access to information, a condition that is almost never fulfilled for health care.

Though it would surely be good to provide more transparent pricing, that would solve little, since there is such variability in product that most consumers rarely shop by price. Except for the rare patient who is willing to leave the country as a medical tourist, no one googles “cheapest CABG,” even while they search for good outcomes.

Ironically, Medicare for All should be a Republican initiative because if health insurance were uncoupled from employment, it would encourage the free movement of labor and would increase efficiency of the free market.

It remains to be seen whether the new Congress will take any definitive action on health care, but it is certain that change is coming. The terms of the debate have changed forever, and the next generation of Americans will demand action on health care, as well as on a variety of other issues.

Notwithstanding the polarization of society now, the next generation offers hope. A poll of 1,052 young Americans age 15-34, conducted in late 2018 by the Associated Press and the National Opinion Research Center (NORC) at the University of Chicago, found that two-thirds of young people favor universal health care.5 A similar percentage also favors tuition-free college education and an increased minimum wage. A slightly smaller percentage, about 60%, favors guaranteed employment and legalization of recreational marijuana. (The margin of sampling error was + 4.3%.)

Most young people view government as a source for good in society. Fifty-eight percent consider the federal government a protector of life and liberty, while 39% consider it a threat. Fifty-six percent think the government should do more to help disadvantaged Americans.

I remain hopeful.

REFERENCES1. Bonchek LI. Who speaks for physicians? We all do. Each one of us.J Lanc Gen Hosp. 2017 (4);12: 97-98.